Thoughts of a GP (family doctor) working for the National Health Service in the UK.

Thursday, 3 July 2008

Incentives

I don't usually discuss politics in this blog, but it seems that the Government has been complaining about us again. Today the BBC reports health minister Ben Bradshaw's complaint that some GPs operate “gentlemen's agreements” not to accept each other's patients, thus blocking patient choice, and that the “lump sum” received by practices dampens the incentive to attract new patients.

I do not think that there are any “gentlemen's agreements”, but GP practices are overstretched and do not want to take on more patients. When practices are full they “close their list” and will not take on any new patients voluntarily. People requiring a GP then have to apply to the local Primary Care Trust (PCT) to be allocated to a practice. (In our practice we think this causes unnecessary bother and complication for patients, and locally we are the only practice that has kept its list open, accepting anyone who lives in our practice area. The PCT recognise this and so they rarely allocate patients to us. We have more patients than we want, but we know that if we closed our list the PCT would start allocating patients to us.) This is not a secret “gentlemen's agreement” but simply application of the existing rules.

The “lump sum” to which Mr Bradshaw refers is more properly called the Correction Factor. It is a kludge, introduced with the new contract because the Government got its sums spectacularly wrong. Under the old contact practices received several different types of NHS income: various allowances (including the Basic Practice Allowance mentioned below), reimbursements of certain expenses such as staff wages, and capitation fees. Only capitation fees varied according to list size, and constituted about 40% of our gross income. The system had grown in a higgledy-piggledy way over the years and there were many inequalities. In particular, practices in deprived areas did not receive as much money as practices in affluent and rural areas. The idea was to replace all all these income sources with one Global Sum, calculated in a very modern and scientific way according to the age distribution and social deprivation of each practice's patients. We were told that there would be some winners and losers, but overall resources would be distributed to the practices that needed them the most. If that were so then one might expect roughly 50% of practices to gain and 50% to lose. When the figures were announced it turned out that over 90% of practices would lose, some by significant amounts. The announcement was made just before GPs were due to vote on accepting the contract and it quickly became clear that we would vote against, since 90% of us would lose out. The GPC (the body that negotiates for GPs) was instructed to tell the Government to postpone the new contract for six months so that the errors in the formula to calculate the Global Sum could be investigated and corrected. But the Government were in a tearing hurry and wanted the new contract accepted immediately. So every practice that lost out under the Global Sum was offered a Correction Factor to bring their basic income back up to what it would have been, to be paid “as long as it was needed”. The contract was duly accepted. Now, just four years later, the Government wants to get rid of it.

It was never clear to me how it would be decided when the Correction Factor would no longer be needed, but since the Global Sum has never been increased it must surely still be necessary. The Government seems to want to get rid of it for idealogical reasons, because it is the only payment that is not proportional to the size of the practice's list of patients. They think that if 100% of our income depended on list size we would have an incentive to expand, but they are wrong.

You may well ask why practices do not expand if they are full. In the Golden Age of general practice (the 1970s and 1980s) this happened all the time. Practices frequently took on new doctors and enlarged their premises to accommodate them. The problem is that it is very difficult to do so under the new contract. Before 2004 only about 40% of our income depended on list size, under the new contract the figure is nearly 100%. The Government thinks that this provides an incentive for practices to expand, but paradoxically it make it more difficult because of the relatively small size of most practices. Under the old contract, when a practice took on a new doctor it would immediately gain a large extra chunk of income called the Basic Practice Allowance. This helped to offset the cost of the new doctor and the income of the existing doctors would only decrease a little. But now that our income is almost totally based on list size, if the average practice of four doctors takes on a fifth doctor the income of the existing four doctors will go down by 20%. GPs may want to improve services to patients, but not at the cost of a 20% pay cut. In addition, it is much more difficult under the new contract for practices to obtain funding to improve and enlarge their premises, so there is often no room to accommodate a new doctor. Finally, at a time of great uncertainty when the Government seems hell bent on destroying existing practices, it is hard to have confidence in the future and practices prefer to be cautious.

These problems arise because practices are small businesses with limited resources. One way of resolving it would be to replace existing practices by huge practices run by big business, and it looks as if Government wants to do just that. Personally I think that the current system of local practices, privately run by a small group of doctors who have an interest in providing good services to patients whom they know well, is better than having huge distant polyclinics run by big business and staffed by sessional doctors. I support the BMA's campaign to preserve and improve the current system. But if the public really wants to scrap local friendly neighbourhood GPs then we will go gracefully. I hope they will miss us.

The fact is that there is both a need for extra GPs to look after patients and a surplus of unemployed trained GPs. The reason? The new GP contract, rushed in with unseemly haste, transparent buy-offs and false assurances by the government.

And the new (Darzi) solution is to bring in a reverse auction for practices with contracts awarded to businesses on a fixed term basis (5 years or so) according to who can provide the most "cost effective " ie cheapest service.

Bye bye personal doctoring from people like you Dr Brown with a lifetime commitment to the area and your patients. Hello to "healthcare" from a "healthcare professsional" who could be anyone from the pharmacist to the healthcare support worker.

I will miss you if you are forced out Dr B. People will only notice what they had after it has disappeared - like the post office.

Speaking as a fellow GP, I think the show is almost over as far as local GPs are concerned, at least in the cities and large towns. The govt is determined to get rid of us and replace us with on-the-cheap nurse-staffed mega-clinics run by their friends in the big corporations. We may survive in the smaller towns and rural areas, where the pickings aren't so rich, at least for a time.

Seems to me that if pay is related to list size Doctors will have to expand their practices in order to stay afloat. However, this will not be feasible at certain sizes and thus will have to recruit more Doctors to a practice. This, however, will not be enough and will have to "entice" patients with extra services and incentives to remain sustainable.

Then practices will have to compete with each other for patients. They will do this by offering as many services as they can.

People complain about how difficult it is to get an appointment with their GP and how little time they have with him, then they complain that GPs limit their list size. We can't have it all ways.

I suppose that what will happen will be that patients gravitate towards their favourite practice, the other local practice will become non-viable and close, leaving local patients without their nearest doctor, and having travelled further to see the other doctor, they will find them so overstretched that they can't get an appointment. Then the doctor that has closed their practice will get a job with the more popular practice, people that didn't like him are stuck with him anyway, and people that did like him will be able to see him but only at the cost of travelling further.

People reading this post may well ask "How come the global sum formula in 2004 came up with such a mess?" Answer: The government interfered with it and removed parts that allowed for the greater running costs of small practices. The result was that 90% of practices were being offered 20-30%less than they had received in the previous year to supply the same basic services. The government's hasty solution? - the \"Correction Factor" This simply gave those practices a correcting sum to ensure they were still funded at 2002-3 levels. It should have disappeared as the global sum was uplifted but the government never increased it and practices are still funded at the same levels as in 2002-3 for costs such as practice staff. The government now wish to remove that correction factor- which will destabilise most Practices - which is what the government want.

Dr Genesis: don't get too depressed. There will always be jobs for primary care physicians, I think.

The real battle is for the preservation of personal doctoring, which the current GP system provides. The alternative is to be a sessional doctor in a VirginSuperHealth Centre which sounds like a lot less fun, though it may still be better than working in hospital. Doctors need motivating, and being responsible for the health of a defined group of patients that you get to know well can be very good for both doctor and patients.

This is a political struggle, we can do nothing without the support of our patients, and battle has been joined. With a bit of luck it will be sorted out by the time you are looking for a GP post.

It seems idiotic that after a careful analysis of social conditions and age of patients, and a careful calculation of the payment needed; they just added up extra money to get payment to the old level. Pfff.

Good luck with that! Here in the Netherlands, GPs receive a basic funding per patient plus can earn extra money if they need to take special care of them (such as diabetes care or asthma care, or some small surgeries and so on). I think it is logical that GPs are now extremely happy to place you in such a "special needs" group...

About me

I am a middle-aged GP working for the NHS in an urban environment somewhere in this sceptred isle (this blessed plot, this earth, this realm, this England).
"Andrew Brown" is a pseudonym and I apologise to the six real Dr Andrew Browns on the GMC's Register of GPs, who are doubtless much better doctors than I.

Lecture note

All diseases are psychosomatic.

About the blog

The name of this blog is a homage to the classic book by John Berger and Jean Mohr. It is in part an attempt to determine whether the modern GP can still be considered fortunate. I like (almost) all my patients, and I hope that this is evident in these stories. I have disguised many details, and the blog is anonymous to further protect their identity. If you think you recognise somebody - you're wrong!